Dr. Grandinetti is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Rockville, Maryland. The views expressed are those of the author and not those of any government agency.
Infected or inflamed lung parenchyma is generally described as community-acquired pneumonia (CAP) or nosocomial pneumonia (NP).1-3 Influenza and pneumonia combined is the seventh leading cause of death in the United States. Pneumonia-associated mortality remains high in patients who are elderly, critically ill, immunocompromised, and with preexisting cardiopulmonary disease.1,4
Each type of pneumonia is associated with causative bacteria, viruses, parasites, or fungi with unique clinical presentations but similar risk factors. Difficulty obtaining sputum samples and results confounded by oropharyngeal colonization make identifying the causative microorganism difficult. Antimicrobial therapy, therefore, is often empiric.5,6
CAP is acquired more than 14 days from a stay in a hospital or long-term care facility. Most CAP patients can be treated safely as outpatients, and mortality is <5%; however, some patients needing close observation, respiratory support, or intravenous (IV) antibiotics require admission to the hospital. Mortality approaches 40% in patients who require intensive care. Prompt treatment (within 4 hours of admission) can improve mortality.1,7,8
NP, occurring 48 hours or more after hospitalization, is the leading hospital-acquired cause of mortality. NP includes ventilator-associated pneumonia and health care?associated pneumonia (HCAP). HCAP occurs in patients who were hospitalized in an acute care hospital for ≥2 days within 90 days of infection; resided in a long-term care facility; received IV antibiotics, chemotherapy, or wound care within 30 days of infection; or attended a hospital or hemodialysis clinic. Recent antibiotic therapy, hospitalization (within 3 months), and late-onset NP (≥5 days after admission), increase the risk for colonization with a multidrug resistant (MDR) organism.2,5,9,10
Nursing Home?Acquired Pneumonia
Nursing home residents are at greater risk for pneumonia with antibiotic-resistant organisms, and pneumonia is the leading cause of death among residents.2 The elderly are prone to conditions causing aspiration and reflux (ie, oversedation, excessive narcotic use, supine positioning, and confusion). Respiratory care interventions and good oral care are important to reduce oropharyngeal colonization with potential respiratory pathogens that can be aspirated.
Monitoring and Counseling Tips for Pharmacists
In All Settings:
In the Hospital:
In Long-Term Care Facilities:
CAP = community-acquired pneumonia; MDR = multidrug resistance. Adapted from references 2,4-6.
Treatment goals are to eradicate causative pathogens, resolve clinical signs and symptoms, minimize hospitalization, and prevent reinfection. The Infectious Diseases Society of America/American Thoracic Society consensus guidelines recommend empiric therapy with macrolides, fluoroquinolones, or doxycycline.4-6 The Centers for Disease Control and Prevention recommends fluoroquinolone use only when patients fail first-line regimens, are allergic to alternative agents, or have a documented drug-resistant pneumococcal infection. Clinicians should consider local epidemiologic and resistant patterns and patient circumstances when basing therapy choices on published guidelines.5,6
Prolonged and unnecessary broad-spectrum anti-infectives are associated with development of resistant organisms. Clinicians should avoid antibiotic overuse and tailor empiric treatment to the causative microorganism as soon as possible. Antibiotics are generally administered for 7 to 14 days; longer treatment durations may be necessary in immunocompromised patients or those infected with atypical pathogens (Legionella pneumophilia, Mycoplasma pneumoniae, Chlamydia pneumoniae). Oral therapy is indicated once patients are clinically stable and able to tolerate oral intake.1,7,9
For patients ≥50 years of age, those with chronic medical conditions, long-term care facility residents, household contacts of high-risk persons, and health care workers, annual vaccination with inactivated influenza vaccine is crucial. The intranasal live attenuated vaccine is indicated for healthy persons aged 5 to 49 years. A one-time pneumococcal vaccine is indicated for patients aged ≥65 and younger patients who are immunocompromised or have long-term medical conditions.11
Pharmacists can influence patient care by ensuring that therapy is initiated quickly with the most appropriate, cost-effective anti-infective, monitoring patient response, and suggesting conversion to oral therapy to shorten hospitalization.
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